ARTICLE IN BRIEF
Five training modules in telemedicine skills are proposed for neurologists in training.
Teleneurology practice has been gaining steam for more than a decade, driven by the huge successes of remote stroke care (telestroke), the ongoing neurologist shortage, the aging of the U.S. population, and the demands of rural health care. Yet while training exists as part of some residency programs and continuing medical education (CME) offerings, there are no national standards for teleneurology curriculum and certification.
A paper published in the August 2 online issue of Neurology with input from the AAN's Telemedicine Work Group hopes to address that, by proposing a curricular framework that could become the nationally standardized basis to train residents in teleneurology — and ultimately medical students, practicing physicians, and allied health professionals as well.
“We are hearing from residency program directors that residents are starting to practice and are being asked for documentation of teleneurology training for credentialing purposes when no formal training curricula exist,” said the lead author of the paper, Raghav Govindarajan, MD, assistant professor of neurology at the University of Missouri School of Medicine and chair of the Telemedicine Work Group. “That's the gap we're trying to address with this curriculum.”
Establishing a curriculum will help create national teleneurology practice standards, replacing the existing patchwork of state and local parameters. “As physicians, we traditionally practice in one geographic location, and our practice is regulated by the state medical board,” said Eric Anderson, MD, PhD, a study co-author, vice chair of the AAN Practice Committee, and director of telemedicine at CortiCare, a US-based telemetry diagnostic company. “In telemedicine, most states have taken it upon themselves to set varying rules and regulations regarding the practice, resulting in potentially 50 differing sets of rules.”
“We want to present a compelling argument and recommendations to the Accreditation Council for Graduate Medical Education [ACGME] to make the teleneurology curriculum an elective for all residencies,” said Bart M. Demaerschalk, MD, MSc, FRCPC, professor of neurology at the Mayo Clinic College of Medicine in Phoenix, AZ, medical director of Synchronous Telemedicine Services at the Mayo Clinic Center for Connected Care, and a member of the AAN Telemedicine Work Group. “Mayo has specified a telestroke requirement in our vascular neurology training, and ACGME will hold us accountable to that, but that's not coming from the top down. There remains an opportunity for ACGME to standardize teleneurology training.”
Among his goals, Dr. Demaerschalk said he would like to see the teleneurology curriculum integrated into all aspects of training, addressing acute and chronic conditions, as well as both hospitals and clinics across neurology specialties.
WHAT PRACTITIONERS NEED TO KNOW
The Neurology paper divides teleneurology training into five basic equivalencies, beginning with fluency with the technology itself — both its abilities and its limitations.
“Seeing your first patients via teleneurology can be a clumsy process, and it is easy for us to forget this once we become more experienced,” said Amanda Jagolino-Cole, MD, assistant professor of neurology at the McGovern Medical School at the University of Texas Health Sciences Center at Houston, whose work in developing telestroke/teleneurology training in the University of Texas's vascular neurology fellowship appeared in a paper last year in Neurology. “Fellows must demonstrate that they are comfortable using the camera, opening images, and completing a note prior to seeing patients — and every trainee starts with different skill sets that pertain to teleneurology.”
The proposed teleneurology curriculum stresses the importance of knowing not only what teleneurology can efficiently do, but also what it may not be best for — vestibular testing, for example, or a comprehensive neuromuscular exam. “Parts of the neurology exam are one of the pitfalls of teleneurology,” said Scott Vota, DO, a co-author on the paper and interim chair of the department of neurology and director of the adult neurology residency program at Virginia Commonwealth University (VCU). “We know it's very helpful in acute stroke and in movement disorders. In neuromuscular diseases, there are some limitations. Evaluating the strength of a muscle or assessing tone are difficult to do over telemedicine.”
Dr. Vota's residents initiated the drive for teleneurology training within the VCU program, which started four years ago. “Learners today want to understand this and know how to use these tools,” he said. “They understand that this is the future of neurology practice.”
Another training module addresses licensure and medicolegal issues and ethics, which become exponentially more complex when teleneurology providers practice across state lines. The Neurology paper suggests a case-based didactic approach to teaching these issues that includes input from legal and regulatory advisors at individual teaching hospitals. Training also touches on interstate reimbursement issues. Residents and practicing physicians need to stay up to date on constantly changing regulations of all types in the states in which they practice, the authors of the paper wrote.
Dr. Anderson pointed out that different risks may apply in different settings. “When you're treating acute stroke patients in an emergency department (ED) setting, for example, you are co-managing a patient with a physician on the other end,” he said. “When you're remotely treating patients in their homes, there isn't necessarily another physician present with the patient, or a telepresenter, and there's potentially a higher legal liability.”
“Webside manners,” the technique of building and maintaining a rapport with patients who are seen remotely, is another critical part of the curriculum. Even in-person bedside manners can be challenging to some residents, and those challenges are often shifted and amplified over video, with touch and physical presence removed from the clinical encounter. “Technology can make it harder to build a relationship,” said Dr. Vota. “Not being in the room, it can be harder to understand non-verbal cues, to know when to pause, when to let the patient speak.”
“Something as simple as introducing yourself as a neurologist, stating where you are located, and explaining why you are seeing the patient via telemedicine rather than in person, can go a long way in establishing rapport,” said Dr. Jagolino-Cole. “We encourage neurovascular fellows and neurology residents to work out proper verbiage for patients and families before getting on the camera.”
Another training module focuses on informed consent, patient privacy, and disclosure. Questions arise about what information the patient is disclosing and who will have access to it, or how much of the patient's environment can be seen on camera, and what that might reveal if they are being examined from their home. And finally, the suggested curriculum addresses skills in remote examination and taking a remote history — either with or without a telepresenter, a health care provider in the room with the patient who can assist with hands-on aspects of the exam, and clinical documentation of telemedicine exams.
BUILDING SPECIALIZED CURRICULA
As teleneurology training advances, a key question will be how to adapt a basic curriculum to the needs of subspecialties and specialized patient populations. “Probably 90 percent or more of teleneurology practice right now is telestroke,” said Dr. Anderson, adding that how telestroke is practiced and its benefits for patients are well-defined. But, he said, “Telemedicine for other neurological conditions — like headache, or epilepsy — is promising, but still relatively lacking. We don't have the same overwhelming body of evidence for those uses yet.”
“We'll need training on telemedicine in critical care; in epilepsy, with remote monitoring of EEGs; in MS; in dementias,” said Dr. Demaerschalk. “There will also need to be some unique facets of working with children via connected care, just as treating them in-person is not the same as treating adults.”
It is already clear that teleneurology is especially valuable for certain patient populations. Steven S. Schreiber, MD, chief of neurology at the Tibor Rubin VA Medical Center in Long Beach, CA, and professor of neurology in residence at the University of California, Irvine, has studied the successes of teleneurology among veterans living in urban areas. “In more rural areas, telemedicine is really crucial because patients often live hundreds of miles away from care sites,” he said. “Our patients in the Veterans Administration health system are only about 40 miles away from our location, but we find that they actually prefer to have their appointments via teleneurology and avoid logistical inconveniences like heavy traffic.”
Teleneurology also makes a marked difference for patients with advanced movement disorders and other incapacitating neurological diseases. “For patients with motor neuron disease, for example, who are on a ventilator, getting out of the house to a medical appointment can consume an entire day,” Dr. Schreiber said. Being examined in their own homes through a 30- to 60-minute teleneurology encounter is far easier and much less stressful for those patients, and visiting nurses can be trained to assist in those exams.
Geographically isolated Native American patients are another group for whom technology can sometimes be the only way to access care. In Arizona, Dr. Demaerschalk has worked with the Indian Health Service to “gradually and respectfully” introduce technology to Indian health care provider sites, an endeavor that he says has been very successful. “Tribal hospitals have been some of our most fabulous partners, and especially given the remoteness of many Native American communities, technology has been extremely useful,” he said.
“Between easing logistics for patients who can't get to care sites, caring for an aging population, and coping with the ongoing dearth of neurologists, remote care will become more and more essential. “People are increasingly becoming aware that telemedicine is an integral part of value-based patient care,” said Dr. Anderson. “The writing is on the wall.”